On the morning of April 23, health ministry officials raided a small diagnostic clinic in Srimushnam town in Tamil Nadu’s Cuddalore district and found two portable ultrasound machines, one placed next to a patient’s bed.

Even though they could not find evidence for the ultrasound machines being misused to determine the sex of foetuses, many other alarming facts came to light.

The clinic, called RK Sonu Scan Centre, was being run by Rajkumar Radhakrishnan, a government doctor. He admitted to have taken the machines from the government primary health centre where he worked.

Subsequently, the team found a third ultrasound machine missing from the primary health centre. Radhakrishnan admitted to having sold that to another private clinic.

RK Sonu Scan Centre neither had patient registration records for the last two years, nor records of Form F, which is used to collate complete information about a pregnant woman, and Form B, which is the certificate of registration issued to a clinic after mandatory checks by the health authorities.

Both the forms are mandatory under the Pre-Conception and Pre-Natal Diagnostic Techniques Act, a law passed in 1994 to reduce sex-selective abortions by making tests that reveal the sex of a foetus illegal.

Health activists suspect such private diagnostic clinics, which have mushroomed across Tamil Nadu in recent years, are clandestinely conducting sex-selective abortions. This is why many districts, they say, have seen a decline in sex ratio at birth, which means fewer female babies are being born compared to male babies.

State government officials have launched a crackdown on these clinics but say the problem lies much deeper: in the worsening gender attitudes in the state.

How Tamil Nadu’s sex ratio varies across districts

Tamil Nadu is considered one of India’s progressive states, with better social indicators than most others. But earlier this year, there was alarm when birth records from the Civil Registration System showed the sex ratio in Tamil Nadu had slipped below many northern states.

This data, however, does not record merely the number of babies born that year but also birth registrations made by adults seeking birth certificates for previous years. This makes it an inaccurate indicator of sex ratio at birth.

Instead, experts rely on the Sample Registration System which collects data on births and deaths annually using a representative sample. The latest SRS data for 2014-’16 shows the sex ratio at birth was 898 in India and 915 in Tamil Nadu, which ranked ninth among India’s 22 bigger states and Union Territories.

Over the last five years, the sex ratio in Tamil Nadu has improved from 918 in 2013-’14 to 931 in 2018-’19, according to Health Management Information System, a digital initiative under the National Health Mission, designed to support planning, management and decision making in health facilities.

But this overall positive picture hides some worrying trends: not only does the sex ratio vary significantly within the state, it has worsened in districts that were doing better earlier.

In the early 1990s, the northern and central districts of Salem, Dharmapuri, Villupuram and Namakkal recorded low sex ratio at births. To address the problem of female babies being abandoned or killed at birth, the state government introduced the cradle baby scheme in Salem in 1992, encouraging parents to leave their ‘unwanted’ girl child in cradles placed at government hospitals.

The sex ratio in these districts has seen a rise, but recent figures show a fall in sex ratio at birth in southern and eastern districts like Thanjavur, Thiruvarur, Pudukkottai, Koilpatti, Paramakudi. For instance, sex ratio at birth in Thanjavur rose from 914 in 2014 to 950 in 2017, but then slipped to 908 in 2018.

Other districts too have seen wide fluctuations over the years. In Cuddalore, for instance, the sex ratio at birth, which had risen from 848 in 2013-’14 to 926 in 2017-18, dropped to 917 in 2019-’20.

The reasons for this wide disparities within the districts remain largely unexplained, though the markers point towards the prevalence of sex-selective abortions, say experts.

“The total male and female births from 2016 to 2019 show several districts [in Tamil Nadu] have recorded sex ratio at birth below 900 and around 900,” said Sabu George, a researcher and member of the National Inspection and Monitoring Committee of the PC-PNDT Act. “Such wide inter-district disparities raise concern over prevalence of sex-selective abortions.”

In 2017, the Tamil Nadu Human Development Report said the inter-district disparities indicated that the process of sex selection was no longer confined to the traditional areas like Salem, Namakkal, Madurai, Dharmapuri, but has moved to other backward districts like Cuddalore and Ariyalur as well.

“It is necessary to reiterate that any effort to address adverse sex ratio needs to be adopted across the State,” the report said. “There are newer districts showing adverse sex ratio and more urban and literate areas seem to exhibit declining sex ratios, thereby indicating that patriarchal system is combination with small family norms may have contributed to this phenomenon.”

How the state is tackling the problem

The state government is making interventions to improve the sex ratio, said a senior official in Tamil Nadu State Health Mission. “Tamil Nadu had earlier recorded post-birth deficit, that is [female] infanticide, but now it is pre-birth deficit,” he said. Post-birth deficit refers to drop in sex ratio because of infanticide, while pre-birth deficit indicates low sex ratio at birth because of sex-selective abortions.

To tackle it, he said the team responsible for the implementation of the Pre-Conception and Pre-Natal Diagnostic Techniques Act “collects the disaggregated data of first, second and third trimester pregnancies from a region and compares it with the second trimester abortions”.

The data collection has become easier with the introduction of a registration software in 2018 that keeps track of all pregnant women who register at public health centres.

“By having this clearly defined specific second trimester audit, we understand the patterns and areas which are doing pre-natal diagnostic tests and sex selective abortions,” he said. “Based on this information, the PC and PNDT Cell targets the areas where it is occurring.”

At the state level, a three-member team is responsible for the implementation of the PC and PNDT Act. It includes a senior officer from the Department of Health and Family Welfare, an eminent woman from a non-governmental organisation and an officer of Law and Judiciary department.

This team puts together a six-member committee with powers to inspect all registered ultrasound centres and assist the state supervisory board in taking action against the centres found to be violating the law.

Similar five-member inspection committees exist at the district level under the chief medical officer or civil surgeon, as well as the municipal level under the medical health officer.

The state official said these teams tend to arrest one or two of the main offenders in their area, sending a warning signal for the others. Between 2013 and 2016, at least 23 doctors were arrested in Tamil Nadu for sex determination, sex-selective abortions, and other violations under the pre-natal diagnostic act, The News Minute reported.

“We do not do make interventions indiscriminately,” said the official. “We are trying to tackle the supply side… To change the demand side means to bring in social changes that will need more time.”

By supply side, the official was referring to the availability of scanning centres that determine the sex of the foetus in the mother’s womb, the presence of quacks and doctors willing to perform abortions, and the availability of over-of-the counter drugs to induce abortions. The demand side is the demand from the parents for sex selection and abortions of female foetuses.

Why this is not enough

But this crackdown on clinics is not enough, partly because inspection committees face challenges in gathering enough evidence to prosecute the accused.

In Cuddalore, for instance, the committee recommended that the registration of RK Sonu Centre be cancelled immediately, the potable machines be seized and detailed investigation be carried out to find how the machines were moved to a private clinic, said a health official in Cuddalore district, who did not wish to be identified. “The report was sent to the State Director of Public Health,” the official said.

But since the committee could not establish the machines were used for sex determination tests, Rajkumar, the government doctor running the centre, was merely suspended from work. No other action could be initiated against him.

In some cases, inspection committees have faced political pressure to go slow on doctors violating the law. “The most notorious doctor was K Ramachandran of Mahalakshmi Nursing Home in Neyveli who used his political influence to threaten even the state inspection and monitoring committee members,” said a senior medical official at the Directorate of Medical and Rural Health Services.

His registration was suspended in May 2016 and he is currently being tried in a court under section 23(1) of the Pre-Conception and Pre-Natal Diagnostic Techniques Act, which relates to revealing the sex of a foetus.

Another problem is the difficulty of preventing those arrested from getting released on bail.

In December 2018, Tiruvannamalai district police arrested 51-year-old Anandhi, a quack who learnt how to use an ultrasound while assisting a doctor. This was the third time in four years that Anandhi had been trapped by the state health department using a pregnant woman as a decoy. Every time, she managed to obtain bail and return to the business of sex selection by moving to a fresh location. She is now in prison waiting for the court trial to begin.

In the same district in 2018, the Directorate of Medical Services found that a quack had helped a doctor named Selvaammal Raman to carry out more than 500 illegal abortions.

Despite the arrests, Tiruvannamalai is one of the districts in the State to have recorded sex ratio at birth of below 900. The total number of registered live births of female child in Tiruvannamalai district from 2016 to 2019 was 45,784 as against 51,769 male child. The aggregate sex ratio at birth of the last three years stood at 884, the lowest in Tamil Nadu.

A question of ethics

For long, a section of the medical community has opposed the PCPNDT Act, on the ground that it creates red tape that is difficult for doctors to navigate. In May this year, the Indian Medical Association released a statement alleging the regulation was unfairly targeting doctors, obstetricians and radiologists.

But others like Sylvia Karpagam, a doctor and activist in Bengaluru, believes this is a sign of a deterioration in medical ethics. “It is not the responsibility of the obstetricians alone, radiologists should take on the ethical responsibility to prevent this practice,” she said.

While it is not clear to what extent access to technology is responsible for the fall in sex ratio in Tamil Nadu, the strong cultural preference for male child remains the primary driver of sex determination tests.

The Tamil Nadu Human Development Report 2017 noted that 16% of women and men want more sons than daughters, but only 7-9 % of men and women want more daughters than sons. However, most women and men would like to have at least one son and at least one daughter.

M Vijayabaskar, professor of economics, Madras Institute of Development Studies, believes worsening economic conditions could be further skewing social attitudes.“The moment finances become a constraint, it is the welfare of the girl child that is immediately hit,” he said.

S Irudaya Raja of Centre for Development Studies had pointed out in an article published in the Economic and Political Weekly in 2003 that the life chances of girl children are dependent on the status of women in society.

While women in Tamil Nadu are faring well in education and employment, intimate partner violence against women in the state has increased, according to the Tamil Nadu State Human Development Index report 2017.

The declining sex ratio at birth could be another indicator of their low social status.

Reassessing state policies

In 1992, after a decade of slipping sex ratio, then Chief Minister J Jayalalithaa introduced the cradle baby scheme to encourage parents leave unwanted girl babies in cradles placed at government hospitals. While the scheme is widely credited with an improvement in sex ration in backward districts like Dharmapuri, Salem and Madurai, some now question its success.

“How will it help change the mindset if parents are encouraged to abandon their girl child?” said an independent researcher working with the State government, who did not want to be identified. “Many of the policy responses here were from a patriarchal mindset.”

The government had also introduced schemes to support enrollment of girl children in schools and provide financial support to the women of marriageable age by providing gold thali (mangalasutra) at the time of the wedding.

“It is in a way stereotyping that one has to spend for girls and government is also a partner in that,” said the researcher. “These cash transfer schemes hardly address the attitudinal problem in society. Earlier infants were killed, now foetuses are being aborted.”